Basic Illustration. Prepared For: Valued Client

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Basic Illustration

Prepared For:

Valued Client

lic #: 3524868

fax: 770-753-3939

ph: 800-891-5824

Alpharetta, GA 30009

Suite 400

312 Maxwell Rd.

LTC Partner

Jack Lenenberg

Prepared By:

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Nationwide Life and Annuity Insurance Company

One Nationwide Plaza

Columbus, OH 43215

ICC19-FLM-1247AO Form #: ICC18-NWLA-583 Issued in: Massachusetts Software Version: 4.6.0.14 - WF Prepared on: 8/6/2020

• Not a deposit • Not FDIC or NCUSIF insured • Not guaranteed by the institution • Not insured by any federal government agency • May lose value

Nationwide CareMatters

®

II

LIFE INSURANCE WITH

Cash Indemnity Long-Term Care Benefits

Prepared for: Valued Client Presented by: Jack Lenenberg LTC Partner 312 Maxwell Rd. Suite 400 Alpharetta, GA 30009 Phone: 800-891-5824 Fax: 770-753-3939 Prepared on: August 6, 2020 page 1 of 24 1

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

ICC19-FLM-1247AO Form #: ICC18-NWLA-583 Issued in: Massachusetts Software Version: 4.6.0.14 - WF Prepared on: 8/6/2020 Dear Valued Client,

Thank you for considering Nationwide® for your long-term (LTC) care planning needs.

The proposal you're about to see was customized for you based on the following information:

Long-term care scenario

Valued Client (Male, 55, Couple Nontobacco, Massachusetts)

Premium received Annual: $12,000.00 Year 1 - Year 10

Total: $120,000.00

Refund of Premium on Surrender Maximum LTC Benefit1

Total Long-term care benefit Day 1: $438,060_{Age 80: $917,200} Maximum monthly LTC benefit Day 1: $5,644_{Age 80: $11,816} LTC specified benefit period 6 years

Inflation protection option 3% Compound

Specified amount (amount accelerated for long-term care)

$135,445.99

Note: The Net Death Benefit may be higher in some years. See Net Death Benefit column of the Tabular Detail.

Guaranteed minimum death benefit $27,089.20 Is Sales Proposal a MEC? Yes

1You have elected the Minimum Refund of Premium with Maximum LTC Benefit Option. The Refund of Premium value is equal to the Cash Surrender Value. This option provides the lowest Refund of Premium value in the early years and the most LTC benefit for a given Premium.

Distinct product features

• Cash Indemnity LTC Benefits • Guaranteed Premiums • Informal Care

• Nationwide Care Guide Network • Guaranteed Cash Value

This policy covers care for a wide range of long-term care services and pays the monthly benefit directly to you, the policy owner. Nationwide CareMatters II was designed to put you in control of your future long-term care choices.

Please review the enclosed information with your insurance professional to determine if Nationwide CareMatters II is right for you.

Thank you.

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

2The insured must meet LTC claims requirements.

Why LTC coverage may be a better

option

Consider a linked benefit policy

Unlike a traditional long-term care policy, a linked benefit policy offers more than just LTC benefits - it's linked to a life insurance policy with a death benefit typically equal to or more than premiums paid. That means a benefit is paid whether you need LTC or not.

Let's take a closer look:

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

3 Benefits may be taxable under certain circumstances. Consult your tax advisor. 4 The insured must continue to meet LTC claims requirements

5 The company that currently provides professional consultation services through the Nationwide Care Guide Network is a member of The National Association of Geriatric Care Managers. This service provider is not affiliated with Nationwide Life and Annuity Insurance Company or its subsidiaries. The service provider and the Nationwide Care Guide Network may be changed or discontinued at any time.

Long-term care support services

The Nationwide Care Guide Network® is a LTC resource and referral service tailored to your geographic

location for policyowners who have purchased Nationwide CareMatters II.5 This service is available to the

policyowner as well as to their spouses, parents, adult children, siblings and parents-in-law.

It's designed to help provide referrals when you need help with the following:

Caregiver support End-of-life care

Home care and housing options Meal and nutrition services

Assisted living or nursing homes Safety and adaptive equipment

Adult day care Transportation

Memory and Alzheimer's care

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

6 This scenario assumes no Loans, Partial Surrenders, or LTC Benefits have been taken.

Total Premium

$120,000

_{Monthly LTC} Benefit: Day One:

$5,644

Age 80:

$11,816

2-Year benefits

Specified Amount

(amount accelerated for

Long-Term Care)

$135,446

4-Year benefits

Extension of Benefit

Rider (LTC Only)

$270,892

6-Year benefit

Total Available for

LTC benefits

Day One

$438,060

Age 80

$917,200

Residual Death

Benefit

$27,089

If the Long-term care benefits are never used, the guarantees below are available.

Guaranteed Death Benefit if LTC is never used.

Day one

$135,446

Age 80

$135,446

Guaranteed Total Received on Surrender.

Day one

$6,783

Age 80

$94,387

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Narrative Summary

About this

Proposal

Payment of the single premium, or paying all premiums during the selected premium payment period, guarantees that the policy will not lapse as long as no policy loans are taken.

This proposal assumes that the premium is paid on the first day of each policy year. The proposal is not a contract and will not become part of any policy issued by Nationwide Life and Annuity Insurance Company. The policy constitutes the actual agreement of coverage and contains the entire terms of the contract. The policy is designed to qualify as life insurance under laws of the United States of America, including the Internal Revenue Code of 1986, as amended. This policy is also intended to be federally tax qualified under section 7702B(b) of the Internal Revenue Code of 1986, as amended. Tax treatment for citizens of, and US residents subject to taxation in, foreign countries may be different. Neither Nationwide nor its representatives give legal or tax advice. Please consult with your attorney or tax advisor for answers to your specific tax questions.

Proposal

Details

Total Required Premium - $120,000 is the sum of all Scheduled Premiums you must pay

(including any rollovers and/or lump sums), based on the Premium Payment Period you selected. The Premium Payment Period is the period during which the Scheduled

Premium will be due and must be selected at issue. The Premium Payment Period for this proposal is a 10-Pay. As long as the premium obligation is met and no loans or partial surrenders are taken, the quoted benefits are guaranteed. For any scheduled premium after the first, there will be a 61 day grace period after the date we mail the grace period notice in which to make the premium payment.

The Scheduled Premium breaks down as follows: 1. Life Insurance Premium - $7,631.54

2. LTC Rider Premium- $562.67

3. LTC Extension of Benefits Premium - $899.58 4. LTC Inflation Protection Rider Premium - $2,906.21

Refund of Premium on Surrender - You have elected the Minimum Refund of Premium

with Maximum LTC Benefit Option. The Refund of Premium value is equal to the Cash Surrender Value. This option provides the lowest Refund of Premium value in the early years and the most LTC benefit for a given Premium.

Total Long-Term Care (LTC) Benefits - $406,338 is the total maximum amount of LTC

benefits available to you from your Nationwide CareMatters® II policy. This amount does

not include the Inflation Protection Option you may have elected.

Maximum Monthly LTC Benefit - $5,644 is the amount you will be paid every month if

you choose to receive the full LTC benefit amount. It does not include amounts that might be provided by any inflation protection option you might have elected.

Specified Amount - $135,446 is the amount used to determine LTC benefits and the

death benefits. It is also used to determine Policy Charges and Deductions from the Accumulated Value. The Specified Amount is not the same as the Net Death Benefit. Please refer to the Net Death Benefit description below or to the tabular detail.

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Cash Indemnity Long-term Care Benefits

Narrative Summary

Proposal

Details

(continued)

Guaranteed Minimum Death Benefit - $27,089 is 20% of the Specified Amount quoted.

As long as your policy stays in force, we guarantee we will pay your beneficiaries a death benefit, even if the death benefit amount quoted is exhausted by the payment of LTC benefits. This death benefit will be lower if loans or partial surrenders are taken.

Inflation Protection Option (Long-Term Care Fixed Rate Inflation Protection Rider Form # ICC18-NWLA-586) - Nationwide CareMatters II offers Inflation Protection Options

of either 3% Simple, 3% Compound, 5% Compound or the U.S. Medical Care Inflation Option. You have elected the 3% Compound inflation option. The monthly benefit provided by the Inflation Protection Rider is not included in the Total LTC Benefit Amount. The monthly Inflation Protection Rider amount is in addition to the Maximum Monthly LTC Benefit amount provided by the LTC Rider, or the LTCEB Rider if elected. This rider must be selected at the time of application and can't be changed after issue.

LTC Specified Benefit Period - 6 years is the benefit period you have selected. This

represents the total period of time LTC benefits may be paid under your policy if the Maximum Monthly LTC Benefit is taken continuously. This includes a 2 Year LTC Rider Specified Acceleration Period and a 4 Year LTC Extension of Benefits Rider Specified Extension Period. Your specified benefit period must be selected at the time of the application and may not be changed after issue. However, taking less than the Maximum Monthly LTC Benefit may extend the length of time over which benefits are payable.

LTC Rider (Form # ICC18-NWLA-584) - Is the rider that provides LTC benefits as an

acceleration of the death benefit.

LTC Extension of Benefits Rider (Form # ICC18-NWLA-585) - Is the rider that provides

benefits once the benefits provided by the LTC rider are exhausted.

Key Policy

Features &

Terms

Accelerated Death Benefit (ADB) for Terminal Illness Rider (ICC13-NWLA-495)

• The ADB Rider advances a portion of the policy's death benefit in the event of a terminal illness (with a life expectancy of 12 months or less).

• The rider is attached to the policy at the time the policy is issued.

• There is no upfront charge for this rider; however, charges and adjustments will apply at the time the claim is approved.

• The receipt of an accelerated death benefit payment may be taxable or may affect Medicaid or public assistance eligibility. Nationwide does not provide tax or legal advice, so you should consult your personal financial advisor to assess the impact of this benefit.

• Nationwide reserves the right to require the base policy Specified Amount be at least $50,000 on the Benefit Effective Date; the remaining Specified Amount, after payment of the ADB Rider Benefit, must be at least the minimum Specified Amount.

• The maximum amount of the ADB Rider Benefit to be paid if the insured meets the requirements of the Eligibility and Conditions for Payment section of the ADB Rider cannot exceed 50% of the base policy Eligible Specified Amount.

Accumulated Value - Is the amount of Life Insurance premium paid, minus premium loads

and administrative charges, minus monthly deductions for cost of insurance minus any partial surrenders, plus interest credited.

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Narrative Summary

Key Policy

Features &

Terms

(continued)

Cash Indemnity LTC Benefits - Once your claim is approved, no monthly bills or receipts

will need to be submitted, and up to full monthly LTC benefit will be paid directly to the policy owner.

Cash Value - Is an amount equal to the greater of:

a. the Accumulated Value of this Policy; or b. the Guaranteed Cash Value.

Cash Surrender Value - Is an amount equal to the greater of:

a. the Accumulated Value of this policy less any surrender charge; or b. the Guaranteed Cash Value.

Cumulative Net Payments - Is the sum of Premiums paid minus any partial surrenders. Eligibility Requirements - In order to receive benefits, no exclusions must apply, and the

following requirements must be met:

• The Insured has been certified within the previous 12 months by a Licensed Health Care Practitioner as requiring Substantial Supervision to protect the individual from threats to health and safety due to severe Cognitive Impairment and/or is unable to perform, without Substantial Assistance from another individual, two or more of the Activities of Daily Living for at least ninety (90) days due to a loss of functional capacity: • Bathing • Continence • Dressing • Eating • Toileting

• Transferring (moving into or out of a bed, chair, or wheel chair) • during the Period of Care, the Insured has been receiving Qualified Long-Term Care

Services specified in a Plan of Care submitted to us;

• The Licensed Health Care Practitioner must be someone other than the owner or an employee of the Eligible Service Provider, or a family member of the Insured;

• The Elimination Period has been satisfied. The Elimination Period has to be satisfied only once while these Riders are in effect;

• you may be required to provide a signed acknowledgment of concurrence with the payment from all parties with an interest in the Policy, including, but not limited to assignees.

• None of the following Exclusions or Preexisting conditions apply:

Exclusions

1. intentionally self-inflicted injuries or attempts at suicide (either while sane or insane);

2. committing or attempting to commit a felony;

3. alcoholism or drug addiction, unless addiction results from administration of drugs for treatment prescribed by a Physician; or

4. war or any act of war, whether declared or undeclared.

Preexisting Conditions Limitations - A preexisting condition is any condition for

which the Insured received medical advice, or treatment was recommended by, or received from, a health care services provider in the six months preceding the Policy Date. We will not pay benefits for Qualified Long-Term Care Services received wholly or in part due to a preexisting condition which is not disclosed in the application if the need for services begins during the first six months after the Policy Date.

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Cash Indemnity Long-term Care Benefits

Narrative Summary

Key Policy

Features &

Terms

(continued)

Guaranteed Cash Value - Is the applicable amount (based on the insured's Attained Age)

from the table of the Guaranteed Cash value. Please refer to the Total Received on Surrender report.

Informal Care - Benefits can be used to pay a family member, or any other individual

deemed appropriate by the Licensed Health Care Practitioner under the insured's customized Plan of Care. Under certain circumstances, benefits may be taxable. Please consult a tax advisor.

International Benefits - If you are receiving Qualified Long-Term Care services outside of

the United States, its territories or possessions, the International LTC benefit payments can be the Maximum Monthly LTC Rider Benefit Amount and the monthly inflation amount. International benefits are not available under the LTCEB rider. Please refer to the client guide for further information on this benefit.

IRC Section 7702 - Provides the rules for the tax qualification of life insurance. The CVAT

test requires we pay a minimum death benefit based on Corridor factors. These factors are defined in section 7702 of the IRS code, and are dependent upon age, class, gender, and rating. If the amount calculated using these Corridor factors in the CVAT is greater than the Specified Amount, then the "Death Benefit" is that higher amount as calculated.

IRC Section 7702B - Provides the rules for the tax qualification of life insurance. The LTC

Rider and the LTCEB Rider are intended to be qualified long-term care insurance contracts under Section 7702B of the Internal Revenue Code of 1986, as amended.

Issue Age - Is the insured's age on the last birthday on or before the policy issue date. Licensed Health Care Practitioner - A Physician, as defined in § 1861 (r)(1) of the Social

Security Act, as amended; a registered professional nurse; licensed social worker; or other individual who meets requirements prescribed by the Secretary of the Treasury. The Licensed Health Care Practitioner must be acting within the scope of his or her license when providing: (a) a certification and/or recertification that the insured is Chronically Ill; or (b) an individualized Plan of Care for the Insured.

Loans (Indebtedness) - Is the amount borrowed against the Net Surrender Value during

the policy year. Any outstanding policy indebtedness will be charged interest at the policy loan interest rate of 4.00% as defined in the policy. Any outstanding policy indebtedness will result in a reduction in the policy's Net Surrender Value, Death Benefit, Total LTC Benefit, and LTC Benefits.

Maximum Monthly LTC Inflation Protection Rider Benefit - Is the full amount of the

benefit available under the Inflation Protection Option after the Maximum Monthly LTC Benefit is taken. This amount is in addition to the Maximum Monthly LTC Benefit. Please consult your policy specification pages for details.

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Narrative Summary

Key Policy

Features &

Terms

(continued)

Modified Endowment Contract (MEC) - This proposal is a MEC as defined by the

guidelines of a MEC as defined by Section 7702A of the Internal Revenue Code. A life insurance policy where premium payments made during the first seven years of the contract, or during the first seven years after a material change, exceed the Modified Endowment Premium limit as defined by section 7702A of the Internal Revenue Code. Withdrawals and loans from these contracts are subject to less favorable tax treatment than distributions from policies which are not Modified Endowment Contracts. This does not apply to distributions for LTC benefits.

Nationwide Care Guide Network® - Is a service provided by a non-affiliated third party

and included at no additional charge. It provides policy owners, insureds and their family members, with free consultations and tailored information to help implement your plan of care. You have no obligation to use these services which are currently provided through a non-affiliated third party. There is no separate additional charge for this service. This service is subject to availability.

Net Surrender Value - Is the Cash Surrender Value of this policy minus any indebtedness

and minus the Unpaid Monthly Deductions Account if applicable.

Net Death Benefit - Is the death benefit amount that will be paid to your beneficiary if the

insured dies while the policy is in-force. This amount is net of any outstanding Policy Indebtedness and LTC benefits paid. Assuming no Loans, Partial Surrenders or LTC Benefits have been paid, this amount will never be less than the total Premiums paid. The Net Death Benefit may be higher in some years based on the Specified Amount,

Accumulated Value, Guaranteed Cash Value, Return of Premium Value, and the IRC 7702 corridor factors.

Partial Surrenders - Is the amount of money withdrawn during the policy year. Partial

Surrenders will result in the reduction of the Cash Surrender Value, Death Benefit, Total LTC Benefit and Monthly LTC Benefit.

Scheduled Premium - Is the amount of Premium required on the first day of the premium

payment frequency for the Premium Payment Period you selected.

Surrender Charges - Is the amount deducted from the Accumulated Value in the event

the policy owner surrenders the policy for cash during the applicable period. At no time will the deduction of the surrender charge cause the policy owner to owe additional funds to Nationwide.

Total Monthly Benefit - is the total benefit amount available to you every month. If an

inflation protection option is elected, the Total Monthly Benefit you receive will be the Maximum Monthly LTC Benefit plus the Maximum Monthly Inflation Benefit. The full Maximum Monthly LTC Benefit must be taken before the Inflation Protection Rider Benefit is available.

Total Received On Surrender - The total dollar amount that will be paid upon surrender

of the policy. The Total Received on Surrender is equal to the Net Surrender Value plus any Refund of Premium amount provided by the Refund of Premium option elected.

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Narrative Summary

Key Policy

Features &

Terms

(continued)

Unpaid Monthly Deductions Account - An account used for tracking purposes. This

account accrues unpaid Policy charges and monthly deductions when Indebtedness exceeds the Accumulated Value. No interest is credited to the Unpaid Monthly Deductions Account. Interest charged on the Unpaid Monthly Deductions Account accrues at the same rate as Indebtedness, and is applied to the Unpaid Monthly Deductions Account.

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Prepared For: Valued Client // Male/55/Couple Non-Tobacco

IRC Section 7702: Cash Value Accumulation Test Specified Amount: $135,445.99

Guaranteed Minimum Death Benefit: $27,089 Total LTC Benefit: $406,337.97

Maximum Monthly LTC Benefit: $5,643.58 LTC Benefit Period: 6 years

Inflation Protection Option: 3% Compound Refund of Premium Option: Maximum LTC Benefit Premium Payment Period: 10-Pay

Scheduled Premium: $12,000.00 Annual

Tabular Detail

Form #: ICC18-NWLA-583 Issued in: Massachusetts Software Version: 4.6.0.14 - WF Prepared on: 8/6/2020

* The Max Monthly LTC Benefit + the Max Monthly Inflation Rider Benefit = The Total Monthly Benefit available. The full Max Monthly LTC Benefit must be taken before the Monthly Inflation Protection Rider Benefit can be taken. The benefit provided by the Inflation Rider will not be added to, nor will it increase or decrease the Total LTC Benefit, the Maximum Lifetime LTC Rider Benefit Amount, the Maximum Lifetime LTCEB Rider Benefit Amount or the Lifetime Total Maximum Amount of LTC Benefits.

** The values shown assume you collect the full amount of LTC Benefits continuously for the full six year LTC Specified Benefit Period you elected and you are receiving qualified LTC services in the United States. Any Monthly Inflation Rider Benefit not taken in a given month will be forfeited. Benefits shown are cumulative over the six year LTC Specified Benefit Period you elected. For example, if you go on claim in year 11 the total benefit $588,716 would encompass claim years 11-16.

Based on Premium Outlay, coverage would continue to: Insured's attained age: 120

All Values and Benefits Guaranteed

Guaranteed 1.00% Interest Rate

Total Max Monthly Max Monthly Total Benefit** Total Net LTC Benefit LTC Benefit* Inflation Total (Total LTC

End of Scheduled Cash Received Death (Excludes (Excludes Rider Monthly Benefit Plus

Year Age Premium Value on Surrender Benefit Inflation) Inflation) Benefit* Benefit Inflation)

1 55 12,000 6,783 6,783 135,446 406,338 5,644 0 5,644 438,060 2 56 12,000 11,591 11,591 135,446 406,338 5,644 169 5,813 451,202 3 57 12,000 16,604 16,604 135,446 406,338 5,644 344 5,987 464,738 4 58 12,000 21,833 21,833 135,446 406,338 5,644 523 6,167 478,680 5 59 12,000 27,289 27,289 135,446 406,338 5,644 708 6,352 493,040 60,000 6 60 12,000 32,979 32,979 135,446 406,338 5,644 899 6,542 507,831 7 61 12,000 38,911 38,911 135,446 406,338 5,644 1,095 6,739 523,066 8 62 12,000 45,088 45,088 135,446 406,338 5,644 1,297 6,941 538,758 9 63 12,000 51,522 51,522 135,446 406,338 5,644 1,506 7,149 554,921 10 64 12,000 58,228 58,228 135,446 406,338 5,644 1,720 7,364 571,569 120,000 11 65 0 60,256 60,256 135,446 406,338 5,644 1,941 7,584 588,716 12 66 0 62,328 62,328 135,446 406,338 5,644 2,168 7,812 606,377 13 67 0 64,448 64,448 135,446 406,338 5,644 2,403 8,046 624,569 14 68 0 66,613 66,613 135,446 406,338 5,644 2,644 8,288 643,306 15 69 0 68,825 68,825 135,446 406,338 5,644 2,893 8,536 662,605 120,000 16 70 0 71,077 71,077 135,446 406,338 5,644 3,149 8,793 682,483 17 71 0 73,364 73,364 135,446 406,338 5,644 3,413 9,056 702,957 18 72 0 75,677 75,677 135,446 406,338 5,644 3,684 9,328 724,046 19 73 0 78,006 78,006 135,446 406,338 5,644 3,964 9,608 745,768 20 74 0 80,345 80,345 135,446 406,338 5,644 4,252 9,896 768,141 120,000 Total Total Total Total page 12 of 24 1

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Tabular Detail

21 75 0 82,688 82,688 135,446 406,338 5,644 4,549 10,193 791,185 22 76 0 85,032 85,032 135,446 406,338 5,644 4,855 10,499 814,920 23 77 0 87,376 87,376 135,446 406,338 5,644 5,170 10,814 839,368 24 78 0 89,720 89,720 135,446 406,338 5,644 5,495 11,138 864,549 25 79 0 92,060 92,060 135,446 406,338 5,644 5,829 11,472 890,486 120,000 26 80 0 94,387 94,387 135,446 406,338 5,644 6,173 11,816 917,200 27 81 0 96,690 96,690 135,446 406,338 5,644 6,527 12,171 944,716 28 82 0 98,961 98,961 135,446 406,338 5,644 6,892 12,536 973,058 29 83 0 101,191 101,191 135,446 406,338 5,644 7,269 12,912 1,002,249 30 84 0 103,366 103,366 135,446 406,338 5,644 7,656 13,299 1,032,317 120,000 31 85 0 105,471 105,471 135,446 406,338 5,644 8,055 13,698 1,063,286 32 86 0 107,487 107,487 135,446 406,338 5,644 8,466 14,109 1,095,185 33 87 0 109,396 109,396 135,446 406,338 5,644 8,889 14,533 1,128,040 34 88 0 111,178 111,178 135,446 406,338 5,644 9,325 14,969 1,161,882 35 89 0 112,820 112,820 135,446 406,338 5,644 9,774 15,418 1,196,738 120,000 36 90 0 114,319 114,319 135,446 406,338 5,644 10,237 15,880 1,232,640 37 91 0 115,675 115,675 135,446 406,338 5,644 10,713 16,357 1,269,619 38 92 0 116,903 116,903 135,446 406,338 5,644 11,204 16,847 1,307,708 39 93 0 118,019 118,019 135,446 406,338 5,644 11,709 17,353 1,346,939 40 94 0 119,051 119,051 135,446 406,338 5,644 12,230 17,873 1,387,347 120,000 Total Total Total Total page 13 of 24 1

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Cash Indemnity Long-term Care Benefits

Tabular Detail

41 95 0 120,048 120,048 135,446 406,338 5,644 12,766 18,410 1,428,968 42 96 0 121,024 121,024 135,446 406,338 5,644 13,318 18,962 1,471,837 43 97 0 121,949 121,949 135,446 406,338 5,644 13,887 19,531 1,515,992 44 98 0 122,817 122,817 135,446 406,338 5,644 14,473 20,117 1,561,472 45 99 0 123,615 123,615 135,446 406,338 5,644 15,077 20,720 1,608,316 120,000 46 100 0 124,334 124,334 135,446 406,338 5,644 15,698 21,342 1,656,565 47 101 0 124,979 124,979 135,446 406,338 5,644 16,338 21,982 1,706,262 48 102 0 125,567 125,567 135,446 406,338 5,644 16,998 22,641 1,757,450 49 103 0 126,103 126,103 135,446 406,338 5,644 17,677 23,321 1,810,174 50 104 0 126,594 126,594 135,446 406,338 5,644 18,377 24,020 1,864,479 120,000 51 105 0 127,061 127,061 135,446 406,338 5,644 19,097 24,741 1,920,413 52 106 0 127,544 127,544 135,446 406,338 5,644 19,840 25,483 1,978,026 53 107 0 128,056 128,056 135,446 406,338 5,644 20,604 26,248 2,037,366 54 108 0 128,553 128,553 135,446 406,338 5,644 21,391 27,035 2,098,487 55 109 0 129,035 129,035 135,446 406,338 5,644 22,203 27,846 2,161,442 120,000 56 110 0 129,502 129,502 135,446 406,338 5,644 23,038 28,682 2,226,285 57 111 0 129,957 129,957 135,446 406,338 5,644 23,898 29,542 2,293,074 58 112 0 130,400 130,400 135,446 406,338 5,644 24,785 30,428 2,361,866 59 113 0 130,834 130,834 135,446 406,338 5,644 25,697 31,341 2,432,722 60 114 0 131,261 131,261 135,446 406,338 5,644 26,638 32,281 2,505,704 120,000 Total Total Total Total page 14 of 24 1

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Cash Indemnity Long-term Care Benefits

Tabular Detail

61 115 0 131,683 131,683 135,446 406,338 5,644 27,606 33,250 2,580,875 62 116 0 132,106 132,106 135,446 406,338 5,644 28,604 34,247 2,658,301 63 117 0 132,539 132,539 135,446 406,338 5,644 29,631 35,275 2,738,050 64 118 0 133,000 133,000 135,446 406,338 5,644 30,689 36,333 2,820,192 65 119 0 133,568 133,568 135,446 406,338 5,644 31,779 37,423 2,904,797 120,000 Total page 15 of 24 1

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Cash Indemnity Long-term Care Benefits

Input Summary - Ledger

Case File: [Untitled]

Screen: Insured Revised Illustration? No

Issue State MA

First Name Valued

Last Name Client

Sex Male

Issue Age or D.O.B. (mm/dd/yyyy) 55

Tobacco User? No

Married / Civil Union / Domestic Partnership?

Yes

Screen: Face Amount and Premium Specify Premium or Benefit Premium

Premium or Benefit Amount 12000 Scheduled Premium 10-Pay

Refund of Premium Maximum LTC Benefit

Premium Mode Annual

Year to Begin Scheduled Premium 1 Benefit Duration 6

Inflation Benefit Option 3% Compound

1035 Exchange? No

Screen: Interest Rate and Income Guaranteed Rate

Screen: Output Design

General Ledger Yes

Annual Cost Summary No Display IRR Column No

Quick View Yes

Premium Summary Yes

OCC Report No

Monthly Cost Summary No

page 16 of 24 1

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3 2

Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Signature Page

ICC19-FLM-1247AO Form #: ICC18-NWLA-583 Issued in: Massachusetts Software Version: 4.6.0.14 - WF Prepared on: 8/6/2020 Life Insurance underwritten by the Nationwide Life and Annuity Insurance Company, Columbus, Ohio.

Proposal as shown is a Modified Endowment Contract.

I have received a copy of this proposal. I also understand this proposal is not a contract and that the terms of the policy constitute the actual agreement of coverage.

Applicant/Policy Owner Date

I certify that this proposal has been presented to the applicant. I have made no representations that are inconsistent with the proposal.

Sales Representative Date

page 17 of 24 1

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3 2

Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Total Received on Surrender

A. Guaranteed Cash Value

B. Accumulated Value Less Surrender Charges

C. Net Surrender Value (the greater of A or B)

D. Refund of Premium Value

E. Total Received On Surrender - The total dollar amount that will be paid upon surrender of the policy. The Total

received On Surrender is the greater of the Net Surrender Value (C) and the Refund of Premium (D). If the Refund of Premium is greater than the Net Surrender Value, the excess will be refunded upon surrender.

Examples:

• If the Refund of Premium is $100,000 and the Net Surrender Value is $70,000, the Total Received on Surrender will be $100,000. The $100,000 will consist of the $70,000 Net Surrender Value and $30,000 Refund of

Premium.

• If the Refund of Premium is $70,000 and the Net Surrender Value is $100,000, the Total Received on Surrender will be $100,000. The $100,000 will consist of the $100,000 Net Surrender Value.

(A) (B) (C) (D) (E)

Guaranteed Accumulated Net Refund Total Received

End of Cash Value Less Surrender Of on

Year Age Value Surrender Charges Value Premium Surrender

1 55 6,783 3,684 6,783 N/A 6,783 2 56 11,591 7,433 11,591 N/A 11,591 3 57 16,604 11,257 16,604 N/A 16,604 4 58 21,833 15,164 21,833 N/A 21,833 5 59 27,289 19,150 27,289 N/A 27,289 6 60 32,979 23,210 32,979 N/A 32,979 7 61 38,911 27,337 38,911 N/A 38,911 8 62 45,088 31,836 45,088 N/A 45,088 9 63 51,522 36,487 51,522 N/A 51,522 10 64 58,228 41,307 58,228 N/A 58,228 11 65 60,256 41,294 60,256 N/A 60,256 12 66 62,328 39,657 62,328 N/A 62,328 13 67 64,448 37,925 64,448 N/A 64,448 14 68 66,613 36,098 66,613 N/A 66,613 15 69 68,825 34,168 68,825 N/A 68,825 16 70 71,077 32,123 71,077 N/A 71,077 17 71 73,364 29,943 73,364 N/A 73,364 18 72 75,677 27,611 75,677 N/A 75,677 19 73 78,006 25,130 78,006 N/A 78,006 20 74 80,345 22,500 80,345 N/A 80,345 page 18 of 24 1

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Total Received on Surrender

Examples:

Premium.

(A) (B) (C) (D) (E)

21 75 82,688 19,719 82,688 N/A 82,688 22 76 85,032 16,778 85,032 N/A 85,032 23 77 87,376 13,660 87,376 N/A 87,376 24 78 89,720 10,346 89,720 N/A 89,720 25 79 92,060 6,828 92,060 N/A 92,060 26 80 94,387 3,102 94,387 N/A 94,387 27 81 96,690 0 96,690 N/A 96,690 28 82 98,961 0 98,961 N/A 98,961 29 83 101,191 0 101,191 N/A 101,191 30 84 103,366 0 103,366 N/A 103,366 31 85 105,471 0 105,471 N/A 105,471 32 86 107,487 0 107,487 N/A 107,487 33 87 109,396 0 109,396 N/A 109,396 34 88 111,178 0 111,178 N/A 111,178 35 89 112,820 0 112,820 N/A 112,820 36 90 114,319 0 114,319 N/A 114,319 37 91 115,675 0 115,675 N/A 115,675 38 92 116,903 0 116,903 N/A 116,903 39 93 118,019 0 118,019 N/A 118,019 40 94 119,051 0 119,051 N/A 119,051 page 19 of 24 1

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3 2

Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Total Received on Surrender

Examples:

Premium.

(A) (B) (C) (D) (E)

41 95 120,048 0 120,048 N/A 120,048 42 96 121,024 0 121,024 N/A 121,024 43 97 121,949 0 121,949 N/A 121,949 44 98 122,817 0 122,817 N/A 122,817 45 99 123,615 0 123,615 N/A 123,615 46 100 124,334 0 124,334 N/A 124,334 47 101 124,979 0 124,979 N/A 124,979 48 102 125,567 0 125,567 N/A 125,567 49 103 126,103 0 126,103 N/A 126,103 50 104 126,594 0 126,594 N/A 126,594 51 105 127,061 0 127,061 N/A 127,061 52 106 127,544 0 127,544 N/A 127,544 53 107 128,056 0 128,056 N/A 128,056 54 108 128,553 0 128,553 N/A 128,553 55 109 129,035 0 129,035 N/A 129,035 56 110 129,502 0 129,502 N/A 129,502 57 111 129,957 0 129,957 N/A 129,957 58 112 130,400 0 130,400 N/A 130,400 59 113 130,834 0 130,834 N/A 130,834 60 114 131,261 0 131,261 N/A 131,261 page 20 of 24 1

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3 2

Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Total Received on Surrender

Examples:

Premium.

(A) (B) (C) (D) (E)

61 115 131,683 0 131,683 N/A 131,683 62 116 132,106 0 132,106 N/A 132,106 63 117 132,539 0 132,539 N/A 132,539 64 118 133,000 0 133,000 N/A 133,000 65 119 133,568 0 133,568 N/A 133,568 page 21 of 24 1

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

7702 / 7702a

ICC19-FLM-1247AO Form #: ICC18-NWLA-583 Issued in: Massachusetts Software Version: 4.6.0.14 - WF Prepared on: 8/6/2020 Single Pay Equivalent = $106,365.61

MEP:

$7,683.44

NSP:

$47,429.28

Modified Endowment Premium (MEP): As defined by the IRC Section 7702A, this premium represents the level annual premium required for seven years to mature the policy under guaranteed mortality charges at an annual interest rate of 4%.

Net Single Premium (NSP): This premium represents the single premium required to mature the policy under mortality charges, as defined in IRC Section 7702, at an annual interest rate of 4%.

Please see the proposal for further information on other important information and features.

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Nationwide CareMatters® II

Cash Indemnity Long-term Care Benefits

Quick View

*The Max Monthly LTC Benefit + the Max Monthly Inflation Rider Benefit at age 80 = The Total Monthly Benefit available at age 80. The full Max Monthly LTC Benefit must be taken before the Monthly Inflation Rider Benefit can be taken. The benefit provided by the Inflation Rider will not be added to, nor will it increase or decrease the Total LTC Benefit, the Maximum Lifetime LTC Rider Benefit Amount, the Maximum Lifetime LTCEB Rider Benefit Amount or the lifetime Total Maximum Amount of LTC Benefits.

**The values shown assume you collect the full amount of LTC Benefits continuously for the full LTC Specified Benefit Period you elected at the beginning of Day 1 or age 80 and you are receiving qualified LTC services in the United States. Any Monthly Inflation Rider Benefit not taken in a given month will be forfeited. Benefits shown are cumulative over the LTC Specified Benefit Period you elected.

***The Inflation Crossover Age is the age that the Total Monthly Benefit is equal to or greater than the Max Monthly Benefit with no inflation added.

All Values and Benefits are Guaranteed

LTC Specified Benefit Period Inflation Protection Option Specified Amount Total Benefit** (Total LTC Benefit Plus Inflation) (Day One) Max Monthly LTC Benefit (Day One) Total Monthly* Benefit (Age 80) Total Benefit** (Total LTC Benefit Plus Inflation) (Age 80) Inflation Crossover Age*** 2 Years None 2 Years 3% Simple 2 Years 3% Compound 2 Years 5% Compound 3 Years None 3 Years 3% Simple 3 Years 3% Compound 3 Years 5% Compound 4 Years None 4 Years 3% Simple 4 Years 3% Compound 4 Years 5% Compound 5 Years None 5 Years 3% Simple 5 Years 3% Compound 5 Years 5% Compound 6 Years None 6 Years 3% Simple 6 Years 3% Compound 6 Years 5% Compound 7 Years None 7 Years 3% Simple 7 Years 3% Compound 7 Years 5% Compound $198,354 $198,354 $8,265 $8,265 $198,354 $184,149 $186,911 $7,673 $13,427 $325,022 58 $166,904 $169,408 $6,954 $14,561 $354,702 61 $135,752 $139,146 $5,656 $19,154 $471,197 63 $196,536 $294,805 $8,189 $8,189 $294,805 $169,923 $262,530 $7,080 $12,390 $453,693 61 $153,196 $236,757 $6,383 $13,365 $495,716 64 $119,835 $188,890 $4,993 $16,909 $639,650 66 $188,239 $376,477 $7,843 $7,843 $376,477 $163,947 $342,649 $6,831 $11,954 $588,570 60 $141,467 $295,922 $5,894 $12,342 $619,595 65 $109,779 $236,580 $4,574 $15,490 $801,143 67 $182,900 $457,249 $7,621 $7,621 $457,249 $158,688 $420,523 $6,612 $11,571 $718,062 61 $136,734 $362,970 $5,697 $11,929 $759,979 65 $103,005 $284,585 $4,292 $14,534 $963,705 67 $178,732 $536,196 $7,447 $7,447 $536,196 $157,207 $506,994 $6,550 $11,463 $860,711 60 $135,446 $438,060 $5,644 $11,816 $917,200 65 $98,204 $333,987 $4,092 $13,856 $1,130,999 68 $176,097 $616,341 $7,337 $7,337 $616,341 $146,918 $560,494 $6,122 $10,713 $946,154 62 $126,628 $485,141 $5,276 $11,047 $1,015,778 67 $94,610 $385,159 $3,942 $13,349 $1,304,286 68 page 23 of 24 1

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3 2

Nationwide Life and Annuity Insurance Company

One Nationwide Plaza

Columbus, OH 43215

ICC19-FLM-1247AO Form #: ICC18-NWLA-583 Issued in: Massachusetts Software Version: 4.6.0.14 - WF Prepared on: 8/6/2020 All guarantees and benefits of the insurance policy are backed by the claims-paying ability of the issuing insurance company. Policy guarantees and benefits are not backed by the broker/dealer and/or insurance agency selling the policy, nor by any of their affiliates, and none of them makes any representations or guarantees regarding the claims-paying ability of the issuing insurance company. Nationwide CareMatters II is a cash indemnity product that pays LTC benefits when the insured person is certified to have a qualifying condition and a need for LTC services. Bills and receipts showing actual expenses do not have to be submitted for payment of benefits once a claim has been approved. Each year, the policy owner can receive, tax free, the greater of the HIPAA per diem amount or actual LTC costs incurred. However, benefits may be taxable under certain circumstances. You may receive, tax free, the greater of the HIPAA per diem in the year of your claim or your actual qualified LTC expenses incurred. Taxpayers should consult with their tax and legal advisors about their specific situation.

Keep in mind that the payment of long-term care rider benefits, as an acceleration of the death benefit, will reduce both the death benefit and cash surrender values of the policy. Additionally, loans and withdrawals will also reduce both the cash values and the death benefit. Care should be taken to make sure that life insurance needs continue to be met even if the rider pays out in full or after money is taken from the policy. There is no guarantee that the rider will cover the entire cost for all of the insured's long-term care, as this may vary with the needs of each insured. Nationwide pays the long-term care benefit to the policy owner; there is no guarantee the policy owner will use the benefit for long-term care expenses if the policy is owned by someone other than the insured.

When choosing a product, make sure that life insurance and long-term care insurance needs are met. CareMatters II is not intended to be a primary source of life insurance protection, so make sure life insurance needs have been covered by appropriate products. Because personal situations may change (i.e., marriage, birth of a child or job promotion), so can life insurance and longterm care insurance needs. Care should be taken to ensure these strategies and products are suitable. Associated costs, as well as personal and financial objectives, time horizons and risk tolerance should all be weighed before purchasing CareMatters II. Life insurance, and long-term care coverage linked to life insurance, has fees and charges associated with it that include: costs of insurance, which vary based on characteristics of the insured such as sex, tobacco use, health and age; and additional charges for riders that customize a policy to fit individual needs.

CareMatters II has exclusions, limitations, reductions of benefits and terms under which the product may be continued in force or discontinued. For more details on cost and coverage options, contact your insurance professional.

The insurance professional or company may contact you in response to your request for additional information. Approval for coverage under the policy and riders is subject to underwriting and may require a medical exam. Nationwide

CareMatters II may not be available in every state. Please contact Nationwide to determine product availability in your state.

The information contained herein was prepared to support the promotion, marketing, and/or sale of life insurance contracts, annuity contracts and/or other products and services provided by Nationwide Life and Annuity Insurance Company.

The Medical Care Component of the Consumer Price Index for All Urban Consumers, Unadjusted (the "Index"), is maintained by the U.S. Bureau of Labor Statistics. Nationwide's use of the Index is not sponsored, endorsed or promoted by the U.S. Bureau of Labor Statistics, The U.S. government, or any of its agencies. Inclusion of the Index in an insurance product is not a recommendation by the U.S. government to buy such a product. Neither the U.S. government nor the U.S. Bureau of Labor Statistics guarantees the adequacy, accuracy, timeliness or the completeness of Nationwide's use of the Index. The actual rate of inflation in long-term care costs may be different than the experience of the Index. Products are issued by Nationwide Life and Annuity Insurance Company, Columbus, Ohio.

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ICC19-NWLA-588

Page 1 of 6 (01/2019)

Long-Term Care Insurance Outline of Coverage

for Long-Term Care Rider (ICC18-NWLA-584)

and Long-Term Care Extension of

Benefits Rider (ICC18-NWLA-585)

Nationwide Life And Annuity Insurance Company

PO Box 182835, Columbus, Ohio 43218-2835  1-800-848-6331 NOTICE TO BUYER: THE RIDERS DESCRIBED IN THIS OUTLINE MAY NOT COVER ALL THE COSTS ASSOCIATED WITH LONG-TERM CARE INCURRED BY THE BUYER DURING THE PERIOD OF COVERAGE. THE BUYER IS ADVISED TO REVIEW CAREFULLY ALL POLICY AND RIDER LIMITATIONS.

CAUTION: The issuance of the Long-Term Care Rider (“LTC Rider”) and Long-Term Care Extension of Benefits Rider (“LTCEB Rider”), if elected, (together, “Riders”) described in this outline is based upon your responses to the questions on your application. A copy of your application is enclosed. If your answers are incorrect or untrue, Nationwide Life and Annuity Insurance Company (“Nationwide”) has the right to deny benefits or rescind these Riders. The best time to clear up any questions is now, before a claim arises! If, for any reason, any of your answers are incorrect, contact us at the address above.

These Riders are attached to an individual Policy of life insurance.

PURPOSE OF OUTLINE OF COVERAGE. This Outline of Coverage provides a very brief description of the important features of the LTC Rider and LTCEB Rider. You should compare this Outline of Coverage to outlines of coverage for other riders available to you. This Outline of Coverage is not the insurance contract, but only a summary of coverage. Only the Riders, and the individual life insurance Policy to which they are attached, contain governing contractual provisions. This means both the Policy and Riders themselves set forth, in detail, the rights and obligations of both you and Nationwide. It is, therefore, important that you READ YOUR POLICY AND RIDERS CAREFULLY.

FEDERAL TAX CONSEQUENCES. THE LTC RIDER AND LTCEB RIDER ARE BOTH INTENDED TO BE A FEDERALLY TAX-QUALIFIED LONG-TERM CARE INSURANCE CONTRACT UNDER SECTION 7702B OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. Benefits paid under these Riders may be taxable, depending on your specific circumstances. As with all tax matters, you should consult your personal tax advisor to assess the impact of this benefit.

TERMS UNDER WHICH THESE RIDERS MAY BE CONTINUED IN FORCE OR DISCONTINUED.

RENEWABILITY. The Policy these Riders are attached to is noncancellable. This means you have the right, subject to the terms of your Policy, to continue your Policy as long as you pay your Scheduled Premium on time. Nationwide cannot change any of the terms of your Policy on its own and cannot change the Scheduled Premium you currently pay.

WAIVER OF PREMIUM. These Riders do not contain a waiver of premium provision. However, if the Accumulated Value has been reduced to less than the required monthly deductions while Rider benefits are being received, any monthly deductions that would otherwise cause the Accumulated Value to be less than zero will be waived. Depending on the Premium Payment Period elected, the Waiver of Premium Endorsement may be available at time of issue. This endorsement waives Premium for the LTC Rider, LTCEB Rider, and LTC Inflation Protection Rider while the Insured is receiving long-term care benefits.

TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS. These Riders are attached to a fixed premium universal life insurance policy which requires payment of all Scheduled Premium as stated in the Policy Specification Pages. The amount of the Scheduled Premium is fixed at issue, so we can never increase the Scheduled Premium for the Policy and attached Riders.

TERMS UNDER WHICH THESE RIDERS MAY BE RETURNED AND PREMIUM REFUNDED. To be certain that you are satisfied with these Riders, you have a thirty day “free look.” Within thirty days after you receive these Riders, you may return it to our Home Office or to the representative who delivered it. We will then void these Riders and the Policy as if it had never been in force and refund to the Policy Owner all Life Insurance Premium and Total LTC Premium paid, including any fees and charges.

Partial Refund of LTC Premium on Surrender

Based on the refund of premium option elected, you may be entitled to a partial refund of premium upon Surrender, if the total Scheduled Premium paid less partial Surrenders multiplied by the Premium Refund Percentage, exceeds the greater of the Cash Surrender Value or the LTC Benefits Paid, the excess amount is refunded up to the Total LTC Premium paid.

Partial Refund of LTC Premium on Death

Based on the refund of premium option elected, you may be entitled to a partial refund of premium upon the death of the Insured, if the total Scheduled Premium less partial Surrenders, exceeds the greater of the death benefit or LTC Benefits Paid, the excess amount will be refunded up to the Total LTC Premium paid.